|Year : 2023 | Volume
| Issue : 1 | Page : 24-28
Dexamethasone as an adjuvant to local anesthetic mixture in brachial plexus block: A prospective randomized double-blind controlled trial
Sahil Garg, Hersimran Kaur, Mandeep Kaur, Manvi Garg
Department of Anaesthesia and Intensive Care, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Haryana, India
|Date of Submission||18-Jan-2023|
|Date of Decision||11-Mar-2023|
|Date of Acceptance||26-Mar-2023|
|Date of Web Publication||25-May-2023|
Dr. Hersimran Kaur
Department of Anaesthesia and Intensive Care, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana - 133 203, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: Peripheral neural blockade is now a well-accepted component of comprehensive anesthetic care. Many adjuvants such as dexmedetomidine, clonidine, opioids, ketamine, and midazolam and corticosteroids have been used; however, still the search for ideal adjuvant is in process. The purpose of this study was to investigate whether addition of 8 mg dexamethasone to local anesthetic solution for brachial plexus block would prolong the period of postoperative analgesia. Materials and Methods: This was a prospective double-blind randomized controlled trial. Forty patients between the age of 20 and 65 years, of either sex of the American Society of Anesthesiologists Grade I-III, who were undergoing upper limb surgery, were selected to study the quality of brachial plexus block and duration of postoperative analgesia produced by addition of dexamethasone to local anesthetic solution versus plain local anesthetic solution in the infraclavicular brachial plexus block. Results: Demographic parameters such as age, weight, height, and body mass index were comparable between two groups with P > 0.05. We also observed that onset of sensory and motor block was earlier in Group I, and duration of motor and sensory block was more in Group I. There was a less requirement of postoperative analgesics. Furthermore, the incidence of postoperative complications was less in Group I compared to Group II. Conclusion: We conclude that addition of dexamethasone to local anesthetic solution for brachial plexus block sets the sensory block early, increases the duration of sensory block without any side effect, provides improved patient comfort, effective pain relief, and decreases the requirement of postoperative supplementary analgesic.
Keywords: Analgesia, brachial plexus block, dexamethasone
|How to cite this article:|
Garg S, Kaur H, Kaur M, Garg M. Dexamethasone as an adjuvant to local anesthetic mixture in brachial plexus block: A prospective randomized double-blind controlled trial. J Ind Coll Anesth 2023;2:24-8
|How to cite this URL:|
Garg S, Kaur H, Kaur M, Garg M. Dexamethasone as an adjuvant to local anesthetic mixture in brachial plexus block: A prospective randomized double-blind controlled trial. J Ind Coll Anesth [serial online] 2023 [cited 2023 Jun 8];2:24-8. Available from: https://www.jicajournal.in//text.asp?2023/2/1/24/377594
| Introduction|| |
Peripheral neural blockade is now a well-accepted component of comprehensive anesthetic care. Its role has expanded from the operating suite into the arena of postoperative and chronic pain management. With appropriate selection and sedation, these techniques can be used in all age groups.
Many adjuvants such as dexmedetomidine, clonidine, opioids, ketamine, magnesium, epinephrine, and midazolam have been used to prolong the duration of analgesia with varying degrees of success; however, still the search for ideal adjuvant is in process. Corticosteroids cause skin vasoconstriction on topical application. They relieve pain by reducing inflammation by blocking transmission in nociceptive C-fibers. They decrease inflammation by inhibiting the action phospholipase A2 responsible for liberation of arachidonic acid leading to the production of prostaglandins and leukotrienes. Steroids produce analgesia by blocking transmission in nociceptive C-fibers and suppressing ectopic neuronal discharge. Corticosteroids and local anesthetics have a combined synergistic analgesic effect.,
Hence, the primary aim of the present study was to evaluate the scope of addition of dexamethasone to anesthetic solution in the infraclavicular brachial plexus block on onset time of sensory and motor blockade, quality of sensory and motor blockade, and duration of blockade, and to compare the results between both the groups. The secondary aim was to study the side effects and complications in both the groups.
| Materials and Methods|| |
This was a prospective randomized double-blind controlled trial. Forty patients between the age of 20 and 65 years, of either sex weighing >50 kg measuring >150 cm in height of the American Society of Anesthesiologists (ASA) Grade I-III, who were undergoing upper limb surgery were selected. Patients on chronic analgesic therapy, history of epilepsy, diabetes mellitus, known allergy to local anesthetic, local infection at the site, coagulation disorders, and patient's refusal were excluded from our study. The patients were randomly divided into two groups, i.e., Group I and Group II of 20 patients each using computer-generated random number table, and the allotted number was secured in a coded opaque sealed envelope as shown in [Figure 1]. The infraclavicular brachial plexus block was given by anesthesiologist who had successfully performed at least 20 infraclavicular brachial plexus blocks with peripheral nerve stimulator as shown in [Figure 2]. Group I received 32 ml of solution containing 15 ml of 2% lignocaine with adrenaline (1 in 200,000) + 15 ml of 0.5% bupivacaine + 2 ml (8 mg) of dexamethasone. Group II received 32 ml of solution containing 15 ml of 2% lignocaine with adrenaline (1 in 200,000) + 15 ml of 0.5% bupivacaine + 2 ml of normal saline. After obtaining approval from the Ethical Committee and Departmental Review Board and ascertaining the selection criteria, written informed consent was obtained from each of the 40 patients for participation in the study.
|Figure 2: Procedure of infraclavicular fossa technique of brachial plexus block|
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Preoperative evaluation was carried out in all patients with a detailed history and physical examination, including height, weight, mental status of the patient, and any other illnesses. Vital parameters were noted, and general and systemic examination was performed. Laboratory investigations, i.e., complete hemogram, urine analysis, bleeding and clotting time, fasting blood sugar, electrocardiogram, and chest X-ray, were carried out in all patients. In preoperative room, Nil per oral status was confirmed, and the patient was shifted to the operation theater. Routine multipara monitors were attached, i.e., heart rate (HR), noninvasive blood pressure (NIBP), and pulse oximeter. A peripheral venous access was secured on the nonoperative upper limb with an 18G Cannula, and administration of lactated Ringer's solution was initiated. The patient was placed in the supine position with the head turned to the contralateral side and arm abducted and elbow flexed at 90°. The infraclavicular fossa was identified, and the site of needle insertion was marked. After preparation of the site, a skin wheal was raised at the site of needle puncture using 2 ml of plain 2% lignocaine solution. An insulated peripheral nerve block needle was inserted at the marked site directed caudally, posteriorly, and medially toward the superior aspect of the second rib. After obtaining an appropriate motor response (i.e., extension of fingers at the metacarpophalangeal joint) with a nerve locator, by serial reduction in the current setting from 2 mA to 0.5 mA, the solution was injected according to the assigned group. Characteristics of the block were assessed by anesthesiologist, who was blind about the group allocation of patients with respect to onset of analgesia (time of injection to time of loss of pain on pinprick), onset of paresis (time of injection to time of onset of motor loss, i.e., partial motor block), onset of paralysis (when patient could not move the arm at all, i.e., complete motor block). The duration of analgesia was taken as time from injection of solution till time of the first analgesic demand postoperatively or when the visual analog scale (VAS) score was >5.
The onset and spread of sensory and motor blockade were assessed every minute after injecting local anesthetic solution. Vital parameters such as HR, NIBP, respiratory rate, peripheral oxygen saturation, and sedation score were monitored every 2 min for the first 20 min, and thereafter, every 5 min till the end of surgery. Surgery was allowed only after satisfactory block was established. The duration of surgery was noted. At the end of surgery, no prophylactic pain relief was given, and patients were transferred to the postanesthesia care unit, where they were monitored to assess the quality and duration of postoperative analgesia by the VAS score every 2 h till 24 h postoperative.
Statistical analysis was done using the Chi-square test for categorical variables and unpaired t-test for continuous variables using IBM-SPSS software (SPSS Statistics for Windows, Version 17.0. Chicago, IL, USA: SPSS Inc.). P < 0.05 was considered statistically significant and <0.001 was considered highly significant. P > 0.05 was considered statistically insignificant.
In our study, we assumed null hypothesis which states that drug combinations used in both the groups will have the same effect.
Sample size calculation
The two independent groups to be compared were of equal size n, and to be drawn from population. Below alpha was the level of significance and equal to 0.05. Similarly, beta was the type-II error whose complement was the power. Sigma was common variance. Delta was difference between the two groups. Z1−α/2 and Z1−β were the respective tail areas under the standard normal curve. We had taken
α = 0.05
Z1−β = 0.84162
Power = 1−β = 0.80
Sigma = 0.48
Delta = 0.55
n = 17.86 ~ 18
As our n = 18, we took a sample size of 20 for each group assuming 10% dropout of patients.
| Results|| |
The demographic characteristics of the patients were comparable, and the results were statistically insignificant (P > 0.05) between both the groups [Table 1]. Both the groups were well-matched for the type and number of surgical procedures, and the results between both the groups were statistically insignificant (P > 0.05) [Table 2]. Onset of sensory blockade in Group I was early compared to Group II and was statistically significant (P < 0.05) [Table 3]. The onset of motor blockade in Group I was early compared to Group II and was statistically significant (P < 0.05) [Table 4]. The mean duration of analgesia in Group I was 14.15 ± 3.70 compared to 5.85 ± 1.63 in groups which showed high statistical significance (P < 0.001) [Table 5]. The total number of the analgesics required in the first 24 h in Group I was lower than in Group II, and the results were highly statistically significant (P < 0.001) [Table 6].
|Table 6: Total number of rescue analgesic doses required in the first 24 h of the postoperative period|
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| Discussion|| |
A study done by Shrestha et al. revealed that addition of dexamethasone for brachial plexus block significantly prolongs the duration of analgesia without any unwanted effect. Similar results were seen in our study. Movafegh et al. studied the addition of dexamethasone 8 mg to lignocaine in axillary brachial plexus block in ASA Grade I-II for elbow, forearm, and hand surgeries and found a significant increase in the duration of sensory and motor blockade. The results were in concordance with our study. Biradar et al. conducted a study to evaluate the effect of dexamethasone added to lignocaine on onset and duration of supraclavicular brachial plexus block. They concluded that dexamethasone addition to local anesthetics hastens the onset and prolongs the duration of motor and sensory blockade. The results are in concordance with our study. Shaikh conducted a study to evaluate the effect of dexamethasone added to local anesthetics in the supraclavicular brachial plexus block. They concluded that patients who received dexamethasone with local anesthetics had a less requirement of rescue analgesic in the postoperative period. Similar results have been obtained in our study. Islam et al. conducted a similar study which showed an early onset of motor blockade and prolonged duration of analgesia similar to our study.
Side effects such as bradycardia, hypotension, respiratory depression, or anaphylaxis to drugs were not seen in either of the groups.
Thus, it was found that addition of dexamethasone for brachial plexus block improved analgesia as manifested by lower pain scores, a prolonged effect, and reduced requirement for rescue analgesics.
| Conclusion|| |
Thus, from the present study, we conclude that addition of dexamethasone to local anesthetic solution for brachial plexus block decreases the onset of sensory and motor blockade, increases the duration of analgesia without any side effect, and decreases the requirement of postoperative supplementary analgesia. Thus, dexamethasone can be used as an adjunct in brachial plexus block.
Limitations of the study
- Dexamethasone can cause increase in blood sugar levels, which was not checked in the study. However, all patients had blood sugar levels within normal range in the preoperative period
- Use of tourniquet in some surgeries can lead to more intensity of pain in that group of patients, which was not taken into consideration and can be a confounding factor.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh N, Gupta S, Kathuria S. Dexmedetomidine versus dexamethasone as an adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol 2020;36:238-43. [Full text]
Duma A, Urbanek B, Sitzwohl C, Kreiger A, Zimpfer M, Kapral S. Clonidine as an adjuvant to local anaesthetic axillary brachial plexus block: A randomized, controlled study. Br J Anaesth 2005;94:112-6.
Karakaya D, Büyükgöz F, Bariş S, Güldoğuş F, Tür A. Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary brachial plexus block. Reg Anesth Pain Med 2001;26:434-8.
Clerc S, Vuilleumier H, Frascarolo P, Spahn DR, Gardaz JP. Is the effect of inguinal field block with 0.5% bupivacaine on postoperative pain after hernia repair enhanced by addition of ketorolac or S (+) ketamine? Clin J Pain 2005;21:101-5.
Lee AR, Yi HW, Chung IS, Ko JS, Ahn HJ, Gwak MS, et al.
Magnesium added to bupivacaine prolongs the duration of analgesia after interscalene nerve block. Can J Anaesth 2012;59:21-7.
Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, Boyaci A. Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: A randomized, double-blinded study. Reg Anesth Pain Med 2003;28:401-5.
Jarbo K, Batra YK, Panda NB. Brachial plexus block with midazolam and bupivacaine improves analgesia. Can J Anaesth 2005;52:822-6.
Ping Y, Ye Q, Wang W, Ye P, You Z. Dexmedetomidine as an adjuvant to local anesthetics in brachial plexus blocks: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017;96:e5846.
Prithvi Raj P. Pain Medicine: A Comprehensive Review. Mosby Publications. 1999259263; 2003.
Glasser RS, Knego RS, Delashaw JB, Fessler RG. The perioperative use of corticosteroids and bupivacaine in the management of lumbar disc disease. J Neurosurg 1993;78:383-7.
Mirzai H, Tekin I, Alincak H. Perioperative use of corticosteroid and bupivacaine combination in lumbar disc surgery: A randomized controlled trial. Spine (Phila Pa 1976) 2002;27:343-6.
Boonstra AM, Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res 2008;31:165-9.
Shrestha BR, Maharjan SK, Tabedar S. Supraclavicular brachial plexus block with and without dexamethasone – A comparative study. Kathmandu Univ Med J (KUMJ) 2003;1:158-60.
Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus blockade. Anesth Analg 2006;102:263-7.
Biradar PA, Kaimar P, Gopalakrishna K. Effect of dexamethasone added to lidocaine in supraclavicular brachial plexus block: A prospective, randomised, double-blind study. Indian J Anaesth 2013;57:180-4.
] [Full text]
Shaikh MR. Role of dexamethasone in supraclavicular brachial plexus block. J Dent Med Sci 2013;1:1-7.
Islam S, Hossain M, Maruf A. Effect of addition of dexamethasone to local anaesthetics in supraclavicular brachial plexus block. J Armed Forces Med Coll 2011;7:11-4.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]